Psychopathology and Psychiatric Disorders in Neuropsychiatric Patients. A Prospective Study.

Dr Ray Goggins, Specialist Registrar in General Adult and Old Age Psychiatry, The Burden Centre, Frenchay Hospital, Bristol, BS16 1JB
raygoggins@amindodyssey.com

ABSTRACT

Aims and Method

Psychiatric morbidity is common in neuropsychiatric patients. The aim of the study was to detect psychiatric morbidity and psychiatric diagnoses in 3 groups of neuropsychiatric patients; inpatients, outpatients and ward referrals from neurology and neurosurgical wards.

54 inpatients at a specialist neuropsychiatry tertiary referral centre (The Burden Centre) were consecutively assessed using self report and observer rated questionnaires and interviews. 40 consecutive outpatients at the Burden Centre and 18 consecutive ward referrals from neurology and neurosurgical wards were assessed in the same manner

Results:

The most common psychiatric diagnoses detected were affective disorders (22-30%), neurotic disorders (10-18%), somatoform and dissociative disorders (18-36%). In general the HADS and the GHQ-28 were useful screening tools while the SCL-90-R, HDRS and MADRS were more specific particularly for detecting depression.

Clinical Implications

Rating scales are useful in screening for psychiatric morbidity and psychiatric diagnoses in neuropsychiatric patients.

Introduction

Neuropsychiatry can be defined as the assessment and treatment of patients with psychiatric symptoms that are associated with definite brain dysfunction or lesions (Yudofsky and Hales 2002). The latter includes conditions such as: traumatic brain injury, cerebral vascular disease, seizure disorders, neurodegenerative diseases, brain tumours, infectious and inflammatory diseases of the central nervous system, alcohol and other substance-induced organic mental disorders and developmental disorders. Psychiatric morbidity is common in neuropsychiatric patients (Trimble 1991). For example in specialty referral clinics for epilepsy, the prevalence is thought to be 25% to 50% (Stevens 1988). Detecting and treating psychiatric morbidity can improve prognosis in both epilepsy and non-epileptic seizures. (Hermann et al. 2000, Muller 2001, Wolf 1997). The aim of the study was to detect psychiatric morbidity and psychiatric diagnoses in 3 groups of neuropsychiatric patients; inpatients, outpatients and ward referrals from neurology and neurosurgical wards.

Method

54 inpatients at a specialist neuropsychiatry tertiary referral centre (The Burden Centre) were consecutively assessed using self report and observer rated questionnaires and interviews. These included the HADS (Hospital Anxiety and Depression Scale (Zigmond and Snaith 1983)), GHQ-28 (General Health Questionnaire 28 (Goldberg and Hillier 1979)), SCL-90-R (Symptom Checklist-90-Revised (Derogatis 1994)), HDRS (Hamilton Depression Rating Scale (Hamilton 1967)), MADRS (Montgomery and Asberg Rating Scale (Montgomery and Asberg 1979)) and SCAN 2.1 (Schedules for Clinical Assessment in Neuropsychiatry (Wing et al. 1990)). There was a 94% response rate. 40 consecutive outpatients at the Burden Centre and 18 consecutive ward referrals from neurology and neurosurgical wards were assessed in the same manner. Response rates of 95 and 94% were achieved respectively.

HADS (Hospital Anxiety and Depression Scale)

The Hospital Anxiety and Depression Scale (HADS) was originally developed for use in hospital settings, as the name suggests. It was designed as a self-completed questionnaire to assess patients' anxiety and depression whilst in in-patient care according to two sub-scales. The Anxiety and Depression scales both comprise 7 questions rated from a score of 0 to 3 depending on the severity of the problem described in each question. The two sub-scales can also be aggregated to provide an overall anxiety and depression score. The anxiety and depression scores are categorised as below:

 

Aggregate Score:-
Interpretation
0-7 Normal
8-10 Mild
11-14 Moderate
15-21 Severe

GHQ-28 (General Health Questionnaire 28)

The General Health Questionnaire (GHQ) is a self-administered screening test, designed to identify short-term changes in mental health (depression, anxiety, social dysfunction and somatic symptoms). It is a pure state measure, responding to how much a subject feels that their present state "over the past few weeks" is unlike their usual state. It does not make clinical diagnoses and should not be used to measure long-standing attributes. The GHQ focuses on the client's ability to carry out "normal" functions and the appearance of any new disturbing phenomena. Designed for use by doctors, psychiatrists and researchers, the GHQ is ideal for use in community and non-psychiatric settings and has four different versions. The GHQ-28 is the most well-known and popular version of the GHQ. Using the Likert scoring (i.e. 0,0,1,1) a cut off score of 4/5 is most effective at separating cases from non cases.

SCL-90-R (Symptom Checklist 90 Revised)

The SCL-90-R is a 90-item self-report symptom inventory designed to reflect the psychological symptom patterns of community, medical and psychiatric respondents.
Each item is rated on a 5 point scale of distress. The SCL-90-R has high validity and reliability in neuropsychiatric population. It has 9 primary symptom dimensions including: Somatisation, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychotism. Caseness is defined by an area t score on the GSI (General severity scale) greater than 62 or 2 area t scores in 2 dimensions greater than 62. An area t score of 63 corresponds to the 90th centile of the appropriate normative population. There are 4 norm groups for each sex: inpatients, outpatients, non patients and adolescents.

HDRS (Hamilton Depression Rating Scale)

The original scale is a 17-item scale which is designed to be used by a skilled psychiatrist, as the completion requires a considerable exercise of clinical skill. The information required for the completion of the scale does not necessarily have to come from an interview and could, indeed, be extracted from many different sources plus a clinical interview. The state of the patient over the previous few days is taken into account, with the recommendation that it is only to be used with patients who already have a diagnosis of depressive illness.

The Hamilton scale has often been reported to be the most sensitive scale for measuring response to treatment and is probably the most widely used scale in research on depression for describing levels of severity in different groups, to ensure an adequate matching or to measure improvements in trials on treatment. The scale has high validity against global judgement and high reliability both with correlations of approximately 0.90. The scale can not be used either for diagnostic purposes or to differentiate types of depression.

 

Scoring:
0-7 None / Minimal depression
8-17 Mild
18-25 Moderate
26+ Severe

MADRS (Montgomery and Asberg Rating Scale)

This scale is the depression part of the CPRS (Comprehensive Psychiatric Rating Scale (Asberg et al. 1978)). The items of this scale were included because of the frequency of occurrence, sensitivity to treatment effect, correlation to outcome and inter-rater reliability. Scoring is based on a flexible interview on a six-point rating scale. The authors suggest the following as an interpretation of scores:

 

0-6 Normal/recovered
7-19 Mild depression
20-34 Moderate depression
35-60 severe depression

Schedules for Clinical Assessment in Neuropsychiatry (SCAN 2.1)

SCAN 2.1 is a structured clinical interview schedule with semi-standardized probes aimed at assessing, measuring and classifying the psychopathology and behaviour associated with the major psychiatric disorders of adult life. Administration time varies between 60 and 90 minutes. Diagnoses can be classified using both ICD-10 and DSM-Iv criteria.

Results:

Table 1 shows results of psychopathology scores in each patient group. Only patients scoring above a defined threshold were included. Table 2 shows ICD-10 psychiatric diagnoses from SCAN 2.1. Some patients had more than one diagnosis. The most common psychiatric diagnoses detected were affective disorders (22-30%), neurotic disorders (10-18%), somatoform and dissociative disorders (18-36%). In general the HADS and the GHQ-28 were useful screening tools while the SCL-90-R, HDRS and MADRS were more specific particularly for detecting depression. Of note 42% of inpatients with a diagnosis of epilepsy had at least one psychiatric diagnosis in addition.

TABLE 1: Results from rating scales

 

Number of Patients	HADS > 10	GHQ-28 > 4	SCL-90-R t score > 62	HDRS > 17	MADRS > 19
Inpatients	31	34	25	17	16
n=54	58%	63%	47%	32%	29%
Outpatients	15	16	16	10	12
n=40	38%	40%	40%	25%	23%
Ward referrals	10	12	11	6	6
n=18	56%	67%	61%	33%	33%

TABLE 2: Psychiatric diagnoses (ICD-10 Criteria from SCAN 2.1)

 

	Epilepsy (ILAE class ification)	Dem entia	Subs-tance Abuse	Alcohol Abuse	Psyc-hotic Diso rder	Affective Disorder (BPAD RDD or Single episode)	Neur-otic Diso-rder	Somat oform and Dissoc iative Dis order	P.D.	L.D
In- patients	39	1	0	10	1	16	10	19	1	10
54	72%	2%	0	18%	2%	30%	18%	36%	2%	18%
Out patients	22	1	2	6	1	9	4	7	1	3
40	54%	2.5%	5%	16%	2.5%	22%	10%	18%	2.5%	8%
Ward Refer- rals	9	1	0	0	1	6	2	6	0	0
18	50%	5.5%	0	0	5.5%	33%	10%	33%	0	0

Discussion

In general the HADS and the GHQ-28 were useful screening tools while the SCL-90-R, HDRS and MADRS were more specific particularly for depression. There are a number of limitations to this prospective study. The samples (inpatients, outpatients, ward referrals) are independent and the numbers are relatively small. However the results are not intended to provide evidence of statistical significance, rather to highlight methods of improving detection rates of psychiatric morbidity.

Conclusion

Rating scales are useful in screening for psychiatric morbidity and psychiatric diagnoses in neuropsychiatric patients.

References:

Asberg, M., Perris, C. Schalling, D. Sedvall. Acta Psychiatri. Scand. Suppl (1978) as part of the comprehensive Psychopathological Rating Scale 271: 5-28.

Derogatis, L. R. 1994 SCL-90-R: Administration, Scoring and Procedures Manual. National Computer Systems, Inc., Minneapolis.

Goldberg, D.P. and Hillier, V.F. (1979). A scaled version of the General Health Questionnaire, Psychological Medicine, 9: 139-145.

Hamilton, M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol. 1967;6:278-296.

Hermann, BP., Seidenberg, M., Bell, B. Psychiatric comorbidity in chronic epilepsy: identification, consequences, and treatment of major depression.
Epilepsia. 2000;41 Suppl 2:S31-41.

Montgomery, SA., & Asberg, M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979; 134:382-389.
Muller, B. 2001. Psychological approaches to the prevention and inhibition of nocturnal epileptic seizures: A meta-analysis of 70 case studies. Seizure 2001; 10: 13-33.

Snaith, RP., Zigmond, AS., The hospital anxiety and depression scale. Manual. NFER Nelson, 1994

Stevens, JR. Psychiatric aspects of epilepsy. J Clin Psychiatry 1988 Apr;49 Suppl:49-57.

Trimble, MR. The Psychoses of Epilepsy. New York: Raven Press; 1991: 210.

Wing, J.K., Babor, T., Brugha, T., Burke, J., Cooper, J.E., Giel, R., Jablensky, A., Regier, D., Sartorius, N. (1990) SCAN: Schedules for clinical assessment in neuropsychiatry. Arch Gen Psych. 47, 589-593.

Wolf, P. 1997. Behavioural therapy. In: Epilepsy: A Comprehensive Textbook, (Eds J. Engel and T.A. Pedley) pp.1359-1364. Lippincott-Raven Publishers, Philadelphia.
Yudofsky, SC., Hales, RE. Neuropsychiatry and the Future of Psychiatry and Neurology. (Editorial) American Journal of Psychiatry 159:8, August 2002.

Zigmond, AS., Snaith, RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67:361-70

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